Clinical UM Guideline


Subject: Outpatient Cystourethroscopy
Guideline #:  CG-SURG-51 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018


This document addresses cystourethroscopy in the outpatient setting.

Clinical Indications

Medically Necessary:

Outpatient cystourethroscopy is considered medically necessary for any of the following indications:

  1. Gross hematuria without evidence of glomerular disease or infection; or
  2. Gross hematuria with blood clots; or
  3. Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy; or
  4. Management of kidney stones unlikely to pass spontaneously; or
  5. Suspected surgical urinary tract injury or foreign body (for example, injury to the ureter, incision into the bladder, intravesical placement or erosion of mesh or suture); or
  6. Urinary urgency, urinary frequency, or urgency incontinence when there is no urinary tract infection (this also includes stress urinary incontinence); or
  7. Suspected malignant involvement of the urinary tract (including diagnosis and staging of bladder cancer, as well as diagnosis and staging of cervical, endometrial, ovarian, vulvar, vaginal, and other gynecologic malignancies); or
  8. Urine leakage from the vagina (for example, from a genitourinary fistula); or
  9. Lower genital tract trauma with suspicion of urinary tract involvement, including urethral stricture; or
  10. Urine dribbling post voiding (for example, from a urethral diverticulum); or
  11. Injection of therapeutic agents for urinary incontinence; or
  12. Verification of suprapubic catheter placement; or
  13. Removal of indwelling ureteral stents not amenable to office-based procedure; or
  14. Recurrent urinary tract infection (defined as 3 or more urinary tract infections in 12 months) when any of the following risk factors are present:
    1. Prior urinary tract surgery or trauma; or
    2. Gross hematuria after resolution of infection; or
    3. Previous bladder or renal calculi; or
    4. Obstructive symptoms (such as straining, weak stream, intermittency, hesitancy), low uroflowmetry or high post void residual; or
    5. Urea-splitting bacteria on culture (for example, Proteus, Yersinia); or
    6. Bacterial persistence after sensitivity-based therapy; or
    7. Prior abdominopelvic malignancy; or
    8. Diabetes or otherwise immunocompromised; or
    9. Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis; or
    10. Repeated pyelonephritis (fevers, chills, vomiting, costovertebral tenderness); or
    11. Asymptomatic microhematuria after resolution of infection.

Not Medically Necessary:

Outpatient cystourethroscopy is considered not medically necessary for any other indication not listed above as medically necessary.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Cystourethroscopy (separate procedure)


Cystourethroscopy with irrigation and evacuation of multiple obstructing clots


Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;


Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis


Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service


Cystourethroscopy, with biopsy(s)


Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands


Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy


Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)


Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)


Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)


Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration


Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia


Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia


Cystourethroscopy, with internal urethrotomy; female


Cystourethroscopy, with internal urethrotomy; male



ICD-10 Diagnosis



All diagnoses, including, but not limited to:


Malignant neoplasm of vulva, vagina, cervix uteri, corpus uteri, uterus, ovary, other and unspecified female genital organs


Malignant neoplasms of urinary tract


Secondary malignant neoplasm of kidney and renal pelvis, bladder and other and unspecified urinary organs


Carcinoma in situ of bladder, other and unspecified urinary organs


Benign lipomatous neoplasm of kidney, other genitourinary organs


Benign neoplasm of urinary organs


Neoplasm of uncertain behavior of urinary organs


Neoplasms of unspecified behavior of bladder, other genitourinary organs


Recurrent and persistent hematuria


Obstructive and reflux uropathy


Calculus of kidney and ureter, lower urinary tract


Calculus of urinary tract in diseases classified elsewhere




Bladder-neck obstruction


Urethritis and urethral syndrome


Urethral stricture


Urinary tract infection, site not specified


Abnormal findings on examination of urine, without diagnosis


Personal history of malignant neoplasm of urinary tract


Personal history of diseases of the urinary system

Discussion/General Information

A cystoscopy is a surgical procedure in which a tube with a small camera on the end (endoscope) is inserted into the bladder to examine the lumen of the bladder, urethra in men and women and the prostate in men. A related procedure, the urethroscopy, is done to examine the urethral lumen to look for urethral diseases or abnormalities. For the cystoscopy, the endoscope is inserted into the urethra which allows visualization of both the bladder and the urethra, thus the term cystourethroscopy. In addition to the camera, small instruments can also be passed through the endoscope that can be used to treat urinary problems. A diagnostic cystourethroscopy can be done as part of an evaluation of abnormal symptoms or laboratory findings. Cystourethroscopy can be performed with local anesthesia while the member is awake, but it can also be performed during or after pelvic surgery with regional or general anesthesia.

Hematuria can occur with or without other urinary tract symptoms. Without symptoms, hematuria may still be indicative of urinary or bladder problems. A 2012 study by Cha reported on 1182 participants who presented with asymptomatic hematuria. A total of 245 participants were found to have bladder cancer; 138 had low-grade tumors while 97 participants had high-grade tumors. While there are limitations to this study, including a possible increased probability of bladder cancer in the cohort based on local referral patterns, the results indicate that hematuria should not be ignored.

Goldberg and colleagues (2008) reviewed the charts of 1584 women who had lower urinary tract symptoms and subsequent cystourethroscopy in an attempt to ascertain whether microscopic hematuria was a reliable predictor of cancer risk. Microscopic hematuria was found in 14.8% of the participants, with 1.7% then found to have biopsy-confirmed bladder cancer. Among the women without hematuria, 0.45% were found to have bladder cancer and 60% of the women presented with a normal initial dipstick urinalysis. While this study has some limitations including its retrospective design, the findings suggest that cystourethroscopy can be used for the evaluation of lower urinary tract symptoms including hematuria.

In a 2015 study of 109 participants with hematuria, Ahmed and colleagues compared transabdominal ultrasound to cystourethroscopy. All participants had both ultrasound and cystourethroscopy. The authors concluded that while ultrasound can be used as a first-line imaging tool for evaluation of hematuria in settings where cystourethroscopy is not available, it cannot replace cystourethroscopy as the gold standard for evaluation of hematuria.

Whether or not a stone passes spontaneously, stone passage can depend on the size and/or location of the stone. According to a 2016 American Urological Association guideline for the surgical management of stones, ureteroscopy can be used for mid or distal ureteral stones.

A 2011 guideline by the Canadian Urological Association (Dason, 2011) provides guidance for the management of recurrent urinary tract infections in women. Urinary tract infection can be considered to be recurrent when it has occurred again after the complete resolution of a previous urinary tract infection. Cystourethroscopy is unnecessary in individuals presenting with uncomplicated urinary tract infections, however certain complicated risk factors suggest complicated urinary tract infections and cystourethroscopy would be warranted.

While cystourethroscopy is considered to be the gold standard procedure for many indications and is a low-risk surgical procedure, like all surgical procedures it is not without risk. A 2014 study by Rambachan and colleagues reported on surgical outcomes and the rate of hospital readmissions following urological surgery. In looking at 7795 participants, outpatient urological surgery had a 3.7% readmission rate within 30 days. Cystourethroscopy and resection of bladder tumor was the most common procedure that had been performed. However, it is important to keep in mind that certain gynecologic surgical procedures themselves are considered to be high-risk for complications and the addition of cystourethroscopy may help to avoid additional surgery.


Cystourethroscopy: A surgical procedure which combines a cystoscopy and a urethroscopy. It can be done to examine the bladder and urethral lumen to look for urethral diseases or abnormalities.

Gross hematuria: Blood in the urine which is visible to the naked eye.

Hematuria: Blood in the urine.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.


Peer Reviewed Publications:

  1. Ahmed FO, Hamdan HZ, Abdelgalil HB, Sharfi AA. A comparison between transabdominal ultrasonographic and cystourethroscopy findings in adult Sudanese patients presenting with haematuria. Int Urol Nephrol. 2015; 47(2):223-228.
  2. Cha EK, Tirsar LA, Schwentner C, et al. Accurate risk assessment of patients with asymptomatic hematuria for the presence of bladder cancer. World J Urol. 2012; 30(6):847-852.
  3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006; 107(6):1366-1372.
  4. Gleason JL. Cystoscopy and other urogynecologic procedures. Obstet Gynecol Clin North Am. 2013; 40(4):773-785.
  5. Goldberg RP, Sherman W, Sand PK. Cystoscopy for lower urinary tract symptoms in urogynecologic practice: the likelihood of finding bladder cancer. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19(7):991-1004.
  6. Rambachan A, Matulewicz RS, Pilecki M, et al. Predictors of readmission following outpatient urological surgery. J Urol. 2014; 192(1):183-188.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Urological Association. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016. Available at: Accessed on April 23, 2018.
  2. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol Assoc J. 2011; 5(5):316-322.
  3. Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol. 2012; 188(6 Suppl):2473-2481. Available at: Accessed on April 23, 2018.
  4. Grossfeld GD, Wolf JS Jr, Litwan MS, et al. Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician. 2001; 63(6):1145-1154.
  5. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation. Health Technol Assess. 2006; 10(18):iii-iv, xi-259.
Websites for Additional Information
  1. National Institute of Diabetes and Digestive and Kidney Diseases. Available at: Accessed on April 23, 2018.
    • Cystoscopy and Ureteroscopy








Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 10/01/2018 ICD-10-CM changes to diagnosis range N35.010-N35.92.



MPTAC review. Updated Definitions section.



MPTAC review. Updated formatting in Clinical Indications section. Updated Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.



MPTAC review. Initial document development.